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Chapter 2
Scalp, Face, Nose and Ears
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.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-1a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-1b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 1
H I S TO R Y
An 85-year-old man noticed the significant darkening of a long time facial lesion.
QUESTIONS
1. Clinically and dermoscopically this could be lentigo maligna.
2. Multiple milia-like cysts and pseudofollicular openings diagnose a seborrheic keratosis.
3. It is not always possible to differentiate follicular openings from pseudofollicular openings and
milia-like cysts.
4. The dark blotch with the bluish tinge is always high risk.
5. The dark blotch has histopathologic correlates that include atypical melanocytes.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
✔ Low
❑
❑ Intermediate
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
❑
✔ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
2-1c
❑
✔
❑
❑
❑
❑
❑
❑
❑
ANSWERS
Answers: 2,3,5
Discussion:
●
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
Follicular openings (boxes)
Pseudofollicular openings
(yellow arrows)
Milia-like cysts (black arrows)
Hyperpigmentation
(white arrows)
Moth-eaten borders
(red arrows)
●
●
●
●
●
Multiple milia-like cysts and pseudofollicular openings characterize this
seborrheic keratosis.
Both criteria can also be found in benign nevi and melanoma.
Dark colors (hyperpigmentation) are commonly found in seborrheic keratosis.
Concave “moth-eaten” borders are one criterion seen in flat seborrheic
keratosis and solar lentigines.
Bluish color is not always high risk.
Blue and/or white color in any intensity should raise a red flag for concern.
In a flat lesion subtle blue and/or white color usually is low risk
In a raised lesion intense blue and/or white color is potentially high risk.
PEARLS
●
●
●
It is essential to differentiate the pseudofollicular openings and milia-like
cysts of a seborrheic keratosis from the follicular openings seen in lentigo
maligna or lentigo maligna melanoma.
One should not stop and diagnose a seborrheic keratosis if milia-like cysts and
pseudofollicular openings are identified before examining the entire lesion.
High-risk criteria pointing to the correct diagnosis might be found elsewhere
and then they would be missed.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-2a-2
2-2a-1
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-2b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 2
H I S TO R Y
The mother of this 7-year-old female is concerned about a blue spot on her daughter’s face. She
wants it treated immediately because the patient’s uncle was recently diagnosed with a melanoma.
The lesion has been present for two years and is not changing.
QUESTIONS
1. Historically, clinically, and dermoscopically this clearly falls within the range of a blue nevus.
2. This could be a combined nevus.
3. This polychromatic lesion with white, blue, and shades of brown color indicates that it is high
risk.
4. Different shades of blue, brown, black, and white can be seen in blue nevi.
5. The multiple follicular openings seen here are as expected on the face.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
✔ Low
❑
❑ Intermediate
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-2c
✔
❑
❑
❑
❑
❑
❑
❑
❑
DISPOSITION
✔ No intervention
❑
❑ Follow-up
❑ Histopathologic diagnosis
ANSWERS
Answers: 1,2,4,5
Discussion:
●
D E R M O S CO P I C C R I T E R I A
●
●
●
Follicular openings (circles)
Brownish blotch (arrows)
Bluish-white color
●
●
●
●
●
●
●
●
In most cases blue nevi are easy to diagnose.
The classic blue nevus is characterized by homogenous featureless blue color
with well-demarcated borders.
Hypopigmentation often scar-like is commonly seen.
Combined nevi contain two different cell populations.
● Blue nevi and compound nevi make up most combined nevi.
Combined nevi can contain various shades and distributions of blue and
brown colors.
Globular-like structures can be seen in blue nevi.
“Black” blue nevi are created by the black lamella (pigmented parakeratosis)
Tape stripping can remove the black lamella, which is a positive clinical sign
pointing toward low-risk pathology.
● The same holds true in whatever lesions that have a black lamella
(ie junctional nevus)
Polychromatic blue nevi should raise a red flag for concern.
PEARLS
●
●
●
The history is essential to help make the correct diagnosis of a blue nevus.
Melanoma and cutaneous metastatic melanoma can be identical clinically
and dermoscopically with a blue nevus.
A “blue” nevus developing in an adult should always raise a red flag for
concern.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
D I AG N O S I S
2-3a
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-3b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 3
H I S TO R Y
This young patient was referred to you for a second opinion because their dermatologist recommended excision of this “fried egg” appearing nevus. It was never examined with dermoscopy and
the referring pediatric dermatologist thought that dermoscopic examination would be beneficial
to help avoid surgery on the child’s face.
QUESTIONS
1. “Fried egg” appearing nevi are always at high risk, histopathologically, and, therefore, dermoscopic evaluation is not indicated.
2. In this age group “fried egg” appearing nevi are usually not high risk and dermoscopy can help
to prove this.
3. Regular dots, globules, and a regular blotch characterize this combined nevus.
4. The dark blotch in an adult should raise a red flag for concern.
5. Sequential digital clinical and dermoscopic monitoring is an alternative to skin biopsy or
excision.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
✔ Low
❑
❑ Intermediate
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-3c
✔
❑
❑
❑
❑
❑
❑
❑
❑
DISPOSITION
❑ No intervention
✔ Follow-up
❑
❑ Histopathologic diagnosis
ANSWERS
Answers: 2,3,4,5
Discussion:
●
D E R M O S CO P I C C R I T E R I A :
●
●
●
Regular dots and globules
(circles)
Islands of normal skin (arrows)
Regular bluish-brown blotch
(star)
●
●
●
●
●
●
Fried egg” appearing nevi should be evaluated with dermoscopy before
more invasive procedures are performed.
In this age group the chances of high-risk pathology are extremely low.
This congenital combined nevus has two cell populations: a blue nevus (the
bluish-brown blotch) and compound nevus.
Combined nevi do not always have a “fried egg” appearance.
If found in a teenager or an adult, the bluish-brown blotch is potentially at
more high risk
The bluish-brown blotch has a differential diagnosis that includes
melanocytic atypia or melanoma.
Islands of normal skin and islands of criteria are one of the patterns commonly
seen in congenital melanocytic nevi.
PEARLS
●
●
Sequential digital monitoring and confident reassurance to the parents that
an excision is not needed would be the optimal cutting-edge approach to
handle this case.
Whatever global patterns and local criteria are identified, one has to decide
if they are regular or irregular, good or bad, low or high risk.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-4a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-4b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 4
H I S TO R Y
A 76-year-old man came for a consultation of a slowly enlarging growth on his nose that started
one year ago.
QUESTIONS
1. Milia-like cysts and pigmented pseudofollicular openings diagnose this pigmented seborrheic
keratosis.
2. Irregular globules and blotches, polymorphous vessels, and regression characterize this
melanoma.
3. The absence of pigment network, arborizing vessels, plus pigmentation diagnoses this basal
cell carcinoma.
4. This pattern of pigmentation and vessels can be found in a basal cell carcinoma or melanoma.
5. Leaf-like structures are present throughout this lesion.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-4c
❑
❑
✔
❑
❑
❑
❑
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 3,4
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Arborizing vessels (red arrows)
Irregular grayish-white blotches
(black arrows)
Follicular openings inside the
lesion (yellow arrows)
Follicular openings outside the
lesions (yellow boxes)
Pseudofollicular openings
(white arrows)
Bony-white color (stars)
●
●
●
●
●
●
An experienced dermoscopist can easily make the diagnosis.
A less-experienced dermoscopist should evaluate all of the criteria found in
the lesion with full knowledge of their definitions.
Melanoma is in the differential diagnosis because of the irregular blackishgray blotches and diffuse bony- white color (regression).
White color is commonly found in basal cell carcinomas and does not represent
true regression.
Pinpoint; irregular linear and other irregularly-shaped telangectatic vessels
(polymorphous vascular pattern) are absent.
The dermoscopic differential diagnosis of the large pseudofollicular opening
includes ulceration.
Ulceration is much more commonly found in basal cell carcinoma than in
melanoma.
Arborizing vessels are not found in seborrheic keratosis.
PEARLS
●
●
●
●
●
There are innumerable shapes and sizes of pigmentation that can be found
in basal cell carcinomas.
One has to only determine if pigment is present or absent.
Adjectives (ie ovoid, leaf-like)describing the shape of pigmentation are not
needed.
The irregular grayish-black blotch at the superior pole fits the definition of a
“leaf-like” structure, yet it has no resemblance to a leaf.
This is an inaccurate concept that is written and taught, which should be
abandoned.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-5a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-5b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 5
H I S TO R Y
This previously long-standing asymptomatic lesion suddenly became raised and tender, but only
for a few days. The patient’s primary care physician was concerned about the sudden change and
thought it was a skin cancer.
QUESTIONS
1.
2.
3.
4.
This is the classic clinical and dermoscopic picture of an inflamed molluscum contagiosum.
This collision tumor consists of a squamous and basal cell carcinoma.
Arborizing vessels and regression characterize this melanoma.
Arborizing “basal cell-like” vessels and whitish-yellow globules characterize this typical sebaceous
gland hyperplasia.
5. Basal cell carcinoma is in the clinical and dermoscopic differential diagnosis of sebaceous
gland hyperplasia.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
✔ Low
❑
❑ Intermediate
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-5c
❑
❑
❑
❑
❑
❑
❑
✔
❑
DISPOSITION
✔ No intervention
❑
❑ Follow-up
❑ Histopathologic diagnosis
ANSWERS
Answers: 4,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
Basal cell-like vessels
(black arrows)
Sebaceous globules
(yellow arrows)
Follicular openings (red arrows)
●
●
●
●
●
This is a classic clinical and dermoscopic sebaceous gland hyperplasia.
The yellowish-white globules would not be seen in a basal cell carcinoma.
By definition “crown” or “wreath-like” vessels said to characterize sebaceous
gland hyperplasia surround and penetrate the lesion, but never reach the
center.
It is not necessary to adhere to this strict definition because it is rarely found
in typical lesions.
“Crown” or “wreath-like” vessels are poor terms that should be abandoned.
Basal cell-like vessels in any distribution plus sebaceous globules make the
diagnosis.
Molluscum contagiosum typically presents with a clear papule that has a
central dell.
● Irregular whitish globules filling a lesion and peripheral linear vessels
along the border have been reported.
PEARLS
●
●
The dramatic and worrisome short-lived change was created by an isolated
pimple that coincidentally developed under the long-standing sebaceous
gland hyperplasia.
In general, it is not always necessary to rush into making a histopathologic
diagnosis in a changing lesion when the change is of a short duration and
the etiology of the change not clear.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-6a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-6b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 6
H I S TO R Y
A 64-year-old ski enthusiast with a history of many sunburns presented with a non-healing lesion
on his nose.
QUESTIONS
1.
2.
3.
4.
5.
This featureless lesion is of no concern.
This feature- poor lesion does not have enough criteria to diagnose a basal cell carcinoma.
Foci of asymmetrical follicular pigmentation are an important clue that this is a melanoma.
Milia-like cysts, pink and gray color, diagnose this irritated seborrheic keratosis.
This feature poor melanoma has asymmetry of color and structure, asymmetrical follicular
pigmentation, pink and gray color, polymorphous vessels, and ulceration.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
❑
✔ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-6c
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 2,3,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
●
Asymmetry of color and
structure
Follicular openings (arrows)
Asymmetrical follicular
pigmentation (boxes)
Diffuse pinkish color
Grayish-white color (black stars)
Polymorphous vessels (circle)
Ulceration (yellow star)
●
●
●
This lesion is feature-poor not featureless.
Feature-poor means that the important criteria are present but not welldeveloped and easy to identify.
Clinically one suspects a basal cell carcinoma but the ulceration is not
enough to make that diagnosis.
Asymmetrical follicular pigmentation is the most specific criteria to diagnose
a melanoma.
The polymorphous vessels (ie pinpoint, linear) could easily be missed if too
much pressure is applied with instrumentation.
PEARLS
●
●
●
●
Pink color should always be a red flag for concern in any lesion.
“If there’s pink, stop and think.”
If one has to spend too much time thinking about what is going on, it is
time to make a histopathologic diagnosis.
This diagnosis came as quite a surprise!
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-7a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-7b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 7
H I S TO R Y
A-39-year-old woman was concerned about a strange-looking spot on her face that did not wash
off with soap.
QUESTIONS
1.
2.
3.
4.
5.
This is a typical make-up tattoo that should be treated with a laser.
This could only be a melanocytic lesion because it has a pigment network.
Lentigines and dermafibromous are non-melanocytic lesions that can have a pigment network.
Branched streaks and irregular globules diagnose this in situ melanoma.
The black stellate macule seen clinically and thickened, branched black pigment network
diagnose this classic ink-spot lentigo.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
✔ Low
❑
❑ Intermediate
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
✔ No intervention
❑
❑ Follow-up
❑ Histopathologic diagnosis
2-7c
❑
❑
❑
❑
❑
❑
❑
✔
❑
ANSWERS
Answers: 3,5
Discussion:
●
●
●
D E R M O S CO P I C C R I T E R I A
●
●
Thick, branched pigment
network (arrows)
Regular dots (circle)
●
●
●
The diagnosis of an ink-spot lentigo can usually be made clinically.
Look for high-risk criteria so that you do not miss an ink-spot lentigo-like
melanoma.
The criteria seen here are not the ones used to diagnose in situ melanoma
on the face (ie asymmetrical follicular pigmentation, annular-granular
structures, rhomboid structures, circle within a circle).
Follicular openings that one expects to find on the face are not found in
every patient.
The dot-like structures represent remnants of the pigment network.
Not all skin lesions with a pigment network are melanocytic (ie lentigo,
dermatofibroma).
PEARLS
●
●
●
Ink-spot lentigines can be associated with a history of excessive sun exposure.
A complete skin examination should be performed to look for more high-risk
pathology (ie skin cancer).
Complete skin examinations should be performed on all patients at the time
one deems appropriate.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-8a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-8b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 8
H I S TO R Y
A 45-year-old man noticed the appearance of a new spot on his face that was getting darker.
QUESTIONS
1. Clinically and dermoscopically this could be an ink-spot lentigo.
2. The absence of a thick black branched pigment network should raise a red flag for concern
that his might not be an ink-spot lentigo.
3. The irregular black blotch, irregular globules and foci of blue-white color characterize this in
situ melanoma.
4. This is too small to be a melanoma; therefore the high-risk dermoscopic picture should be
ignored.
5. The isolated pseudofollicular opening, milia-like cysts, and sharp demarcation diagnose this
small seborrheic keratosis.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
✔ Intermediate
❑
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-8c
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 1,2,3
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
Irregular black blotch
(white star)
Follicular openings
(red arrows)
Pseudofollicular opening
(white arrow)
Irregular globules (white circles)
Blue-white color (black arrows)
●
●
●
●
The history and dermoscopic picture are worrisome.
An ink-spot lentigo might look like this dermoscopically however, without
the prominent pigment network it falls out of the range of a classic lesion.
One has to create a dermoscopic differential diagnosis for the round white
structures (ie milia-like cysts vs follicular openings).
Milia-like cysts and psuedofollicular openings can be seen in melanoma.
This entire picture warrants a histopathologic diagnosis even if it is in a
cosmetically sensitive area.
Melanomas can start as a speck and remain less than 6mm for long periods
of time.
PEARLS
●
●
●
●
Destructive therapy without a positive histopathologic diagnosis could be
disastrous.
If after destructive therapy without a previous histopathologic diagnosis a
lesion like this recurs, a histopathologic diagnosis should now be made
posthaste.
“Melanoma incognito” aka false negative melanoma can mimic benign or
other malignant lesions.
“Melanoma incognito” can clinically and/or dermoscopically mimic seborrheic keratosis, vascular lesions, basal cell carcinoma combined, recurrent,
Spitz, blue and dysplastic nevi, actinic keratosis, or solar lentigines.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
D I AG N O S I S
2-9a
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-9b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 9
H I S TO R Y
There is only a two-month-history of this asymptomatic pigmented skin lesion on the ear of a
30-year-old man.
QUESTIONS
1.
2.
3.
4.
This is a melanocytic lesion because there are multiple brown globules.
This is the typical dermoscopic appearance of a secondarily infected wound.
This is an atypical “Spitzoid” global pattern because there are foci of irregular streaks.
Asymmetry of color and structure, irregular globules, irregular streaks an irregular black
blotch plus regression characterizes this melanoma.
5. An atypical “Spitzoid” pattern seen with dermoscopy does not always correlate with a
“Spitzoid” melanoma histopathologically.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-9c
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 1,3,4,5
Discussion:
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
Asymmetry of color and
structure
Irregular globules (circles)
Irregular streaks (arrows)
Irregular black blotch
(white star, white arrows)
Regression (black star)
●
●
●
●
●
A regular/good/low risk “Spitzoid” pattern, aka “Starburst” pattern, can have
streaks and/or dots and globules at most points along the periphery of the
lesion.
An atypical “Spitzoid” pattern can have foci of streaks and/or dots and globules
at some points along the periphery of the lesion.
There are only streaks connected to the irregular black blotch which fits the
definition of irregular streaks.
Inter-observer agreement among experienced dermoscopists is not good and
another clinician might not agree that this is an atypical “Spitzoid” global
pattern.
The grayish-white regression area fills half of the lesion.
“Spitzoid” dermoscopic patterns are not always “Spitzoid” histopathologically.
PEARLS
●
●
●
●
●
●
Even regular “Spitzoid” patterns can be seen in melanoma.
All lesions with this pattern of criteria should be removed no matter how
old or young the patient.
There would not be a good dermoscopic–pathologic correlation if the
histopathologic report was that of a benign lesion.
Speak with your pathologist about the asymmetrical dermoscopic appearance
of the criteria.
A reevaluation of the specimen might be indicated.
Do not hesitate to ask for another histopathologic opinion with a
pigmented-lesion expert if there is not a good dermoscopic–pathologic
correlation.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-10a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-10b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 10
H I S TO R Y
During a routine total body skin examination, this pigmented skin lesion was found in the scalp of
an 83-year-old woman.
QUESTIONS
1.
2.
3.
4.
The clinical and dermoscopic differential diagnosis includes a seborrheic keratosis.
The clinical and dermoscopic differential diagnosis includes an ulcerated basal cell carcinoma.
The clinical and dermoscopic differential diagnosis includes invasive melanoma.
The dermoscopic differential diagnosis of the irregular brown color includes irregular blotch
vs ulceration.
5. The absence of arborizing vessels rules out a basal cell carcinoma.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
1
2
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
3
1
2-10c
❑
❑
❑
✔
❑
❑
❑
❑
❑
ANSWERS
Answers: 2,3,4
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
Discussion:
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Asymmetry of color and
structure
Multicomponent global
pattern (1,2,3)
Irregular dots and globules
(white boxes)
Irregular grayish-black blotches
(yellow arrows)
Ulceration (white arrows)
Regression (yellow stars)
●
●
●
●
●
●
●
Strict analysis of the criteria favors the diagnosis of a melanoma.
● Globules identify a melanocytic lesion:
● Basal cell carcinomas can have pigmented globular-like structures that
cannot be differentiated from the dots and globules of a melanocytic
lesion.
● Asymmetry of color and structure
● Multicomponent global pattern
● Irregular dots and globules
● Irregular blotches
● Regression
Basal cell carcinomas do not always have arborizing vessels.
Basal cell carcinomas do not always have pigment.
Spoke-wheel structures, which are not seen here, might be the only clue to
diagnose a basal cell carcinoma.
It is not always possible to be 100% sure of global patterns and local criteria.
One has to be able to create a dermoscopic differential diagnosis for global
patterns and local criteria.
The multicomponent global pattern (three or more different areas within a
lesion) is not diagnostic of melanoma.
The multicomponent global pattern can be seen in melanocytic,
non-melanocytic, benign, and malignant lesions.
PEARLS
●
●
●
●
In this case, dermoscopy has been clinically helpful. Clearly this is not a
seborrheic keratosis that needs no intervention. Even though one cannot be
sure if this is a basal cell carcinoma or melanoma we know that a
histopathologic diagnosis is indicated.
It is essential to be familiar with all of the classic examples of global patterns
and local criteria.
One will need that knowledge to be able to create a dermoscopic differential
diagnosis when the occasion arises.
Regularly one has to think in terms of dermoscopic differential diagnosis.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-11a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-11b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 11
H I S TO R Y
While washing this seven-year-old girl’s hair, her mother found this asymptomatic spot in her scalp.
QUESTIONS
1.
2.
3.
4.
5.
More than 50% of this lesion demonstrates regressive changes pathognomonic of a melanoma.
There are no clues to differentiate hypopigmentation from regression in this lesion.
Gray color and foci of “peppering” are the criteria to diagnose the regression in this lesion.
The more regression in a lesion the greater the chance it is a melanoma.
Irregular dots and globules, irregular blotches, plus regression characterize this dysplastic nevus.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
✔ Intermediate
❑
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-11c
❑
✔
❑
❑
❑
❑
❑
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
❑
✔ Histopathologic diagnosis
ANSWERS
Answers: 3,4,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
Irregular dots and globules
(box)
Irregular blotches (black arrows)
Regression (star)
Gray color (white arrows)
Peppering (circles)
●
●
●
●
●
●
●
Regression is not diagnostic of melanoma.
Regression can be seen in melanocytic, non-melanocytic, benign, and malignant
lesions.
The more regression the greater the chance of high-risk pathology (ie
dysplastic nevi, melanoma).
It is not possible to differentiate this dysplastic nevus from a melanoma
using dermoscopy.
One might not be able to differentiate hypopigmentation from true regression.
The white color of regression should be lighter than the surrounding skin.
Gray color indicates that melanin is in the papillary dermis.
The fine granules of “peppering” represent free melanin and/or
melanophages in the papillary dermis.
Gray color and “peppering” are found in regression not in hypopigmentation.
PEARLS
●
●
●
●
●
●
●
The identification of regression is a red flag for concern.
Proceed with focused attention and look for other high-risk criteria.
In this age group one would expect to find a globular pattern with regular
dots and globules.
There is not a good clinico–dermoscopic correlation–another red flag for
concern
Not all scalp nevi in children need to be excised, especially if they have a
banal clinical and dermoscopic appearance.
Dysplastic nevi are commonly found in the scalp of children.
It is essential to include the scalp in a complete skin examination.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-12a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-12b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 12
H I S TO R Y
A first-year-dermatology resident found this small pigmented lesion after a complete skin examination
in a pediatric dermatology clinic. The parents had not been aware of it.
QUESTIONS
1.
2.
3.
4.
Regular dots and globules characterize this classic cobblestone pattern.
Irregular dots and globules are one important feature of this dysplastic nevus.
The multifocal hypopigmentation seen here is a site-specific criterion just found in the scalp.
Asymmetry of color and structure, irregular dots and globules and hypopigmentation characterize this dysplastic nevus.
5. Asymmetry of color and structure, irregular dots and globules, regression and a milky-red area
characterize this dysplastic nevus.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
✔ Intermediate
❑
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
2-12c
❑
✔
❑
❑
❑
❑
❑
❑
❑
ANSWERS
Answers: 2,5
Discussion:
●
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
Asymmetry of color and
structure
Irregular dots and globules
(circles)
Regression/whitish gray color
(white arrows)
Milky-red area (box)
●
●
●
●
●
●
As in Case 11 there is not a good clinico–dermoscopic correlation here.
A red flag for concern.
One would expect to see the cobblestone global pattern with regular larger,
angulated globlules.
Dots and globules with different sizes and shapes, scattered throughout the
lesion are considered irregular by definition.
The grayish-white area of regression is widespread.
Multifocal hypopigmentations, not found here, would be one criterion
commonly found in dysplastic nevi.
There are no site-specific criteria found only on the scalp that are not found
elsewhere on the body.
The milky-red area does not contain out-of-focus, globular-like structures.
In this case, the milky-red area is non-specific and is not indicative of
melanoma.
PEARLS
●
●
●
●
●
Do not be surprised to find nevi in the scalp of children.
Do not be surprised to find atypical dermoscopic criteria in this location.
In this case if the pathology report was not at least a dysplastic nevus, there
would not be a good dermoscopic–pathologic correlation.
When one does not have a good dermoscopic–pathologic correlation, speak
with your pathologist.
When one does not have a good dermoscopic–pathologic correlation,
consider getting a pigmented-lesion expert’s pathologists opinion.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-13a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-13b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 13
H I S TO R Y
A 78-year-old female had a basal cell carcinoma excised 8 years ago from her scalp. There is now a
new lesion adjacent to the surgery scar.
QUESTIONS
1.
2.
3.
4.
5.
This recurrent basal cell carcinoma is filled with typical arborizing vessels.
This melanoma is filled with pinpoint and cork screw vessels.
This lesion is filled with hairpin vessels.
Hairpin vessels and gray color characterize this irritated seborrheic keratosis.
At times, it may be challenging to accurately categorize small vessels but an attempt always
helps.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
✔ Low
❑
❑ Intermediate
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
✔ No intervention
❑
❑ Follow-up
❑ Histopathologic diagnosis
2-13c
❑
✔
❑
❑
❑
❑
❑
❑
❑
ANSWERS
Answers: 3,4,5
Discussion:
●
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Classic hairpin vessels
(black boxes)
Non-perfect-shaped hairpin
vessels (yellow boxes)
Pinpoint vessels (circles)
Linear vessels (red boxes)
Gray color (black arrows)
Brown color (yellow arrows)
●
●
●
●
Clinically, but not dermoscopically, this appears to be a basal cell carcinoma.
Arborizing vessels are not seen anywhere.
Basal cell carcinomas do not always have classic arborizing vessels.
This lesion is filled with classic and not-so-classic hairpin vessels.
There are no thick, irregular hairpin-shaped vessels that can be found in
melanoma.
The grayish color is the clue that there is inflammation.
The brown color and pinpoint vessels have no diagnostic significance.
PEARLS
●
●
●
●
●
A recurrent basal cell carcinoma after so many years would be unusual.
A new primary basal cell carcinoma may happen to arise coincidentally in
the same area.
None of the specific shape designations given to vessels are pathonomonic
of any specific pathology.
Inter-observer agreement on the exact shape of blood vessels within a given
lesion might vary with the personal experience of the individual.
Polarizing instrumentation, ultrasound gel and minimal pressure should be
applied to better visualize small vessels.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-14a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-14b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 14
H I S TO R Y
A mother was worried about an enlarging growth by the right ear of her six-year-old child.
QUESTIONS
1. Clinically and dermoscopically this could be an amelanotic melanoma.
2. Clinically and dermoscopically this could be a Spitz nevus.
3. Different shades of pink color and polymorphous vessels are diagnostic of this amelanotic
melanoma.
4. One can see pinpoint, linear, and hairpin vessels.
5. A vascular pattern in a pink lesion is one of the sub-types of Spitz nevi.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-14c
✔
❑
❑
❑
❑
❑
❑
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 1,2,4,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Different shades of pink color
White color
Linear vessels (black arrows)
Pinpoint vessels (boxes)
Hairpin vessel (yellow arrow)
Milia-like cyst (circle)
●
●
●
●
●
●
●
Amelanotic melanoma is a common subtype in this age group.
Different shades of pink color and centrally-located vessels are commonly
found in amelanotic melanoma, yet are not diagnostic.
There are six dermoscopic patterns seen in Spitz nevi: starburst, globular,
homogeneous, reticular, vascular, and atypical.
Overlapping of patterns criteria can be found.
All of the patterns can be seen in children.
This lesion demonstrates the vascular pattern.
Absence of pigment and vessels creates the pink color.
The milia-like cyst has no diagnostic significance.
Structures identical to milia-like cysts can represent mucoid degeneration
and can be seen in melanomas.
PEARLS
●
●
●
Dermoscopy is more sensitive and specific to diagnose pigmented lesions.
Classic patterns and their variations are commonly found in Spitz nevi.
Pink lesions in any age group should raise a red flag for concern.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
D I AG N O S I S
2-15a
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-15b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 15
H I S TO R Y
An 80-year-old female with a history of recurrent lentigo maligna on the right side of her face
developed a new blue papule by her left ear.
QUESTIONS
1. This could be a de novo melanoma characterized by irregular blotches, blue-white color, and
regression.
2. This could be a heavily pigmented basal cell carcinoma without arborizing vessels and ulceration.
3. Commonly, basal cell carcinomas have such extensive pigmentation.
4. Uncommonly, basal cell carcinomas have such extensive pigmentation.
5. Without arborizing vessels and spoke-wheel structures, one cannot diagnose a basal cell
carcinoma.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-15c
❑
❑
✔
❑
❑
❑
❑
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 1,2,4
Discussion:
●
D E R M O S CO P I C C R I T E R I A
●
●
●
Ulceration (yellow arrows)
Bluish-white color (stars)
Purplish color (red arrows)
●
●
●
●
●
●
●
●
●
●
●
With strict adherence to the definitions of the dermoscopic criteria, it is not
possible to differentiate a basal cell carcinoma from melanoma.
The bluish-white color has a dermoscopic differential diagnosis.
Found in basal cell carcinomas and melanomas.
Islands of pigmented basal cell carcinoma cells.
Deep dermal heavily pigmented atypical melanocytes.
The irregular dark color has a dermoscopic differential diagnosis.
Ulceration vs irregular blotches.
Blotches representing heavily pigmented atypical melanocytes.
The reddish color represents vascularization.
Most basal cell carcinomas are not so heavily pigmented.
The minority of basal cell carcinomas have spoke-wheel structures.
Basal cell carcinomas do not always have arborizing vessels.
PEARLS
●
●
●
In general it is not possible to be 100% sure of a given diagnosis.
Be prepared to create a dermoscopic differential diagnosis.
Err on the side of the most aggressive pathology when planning your
surgical approach.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-16a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-16b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
y
CASE 16
H I S TO R Y
A barber found this lesion on the scalp of a 61-year-old man.
QUESTIONS
1. Compared to Case 15, this basal cell carcinoma is easier to diagnose because there are classic
arborizing vessels.
2. A bluish-white veil and irregular blotches plus corkscrew vessels characterize this melanoma.
3. Arborizing vessels are always thick and branch at 90° angles.
4. Typically the arborizing vessels seen in basal cell carcinomas are in—focus because they are
located on the surface of the lesion.
5. In or out- of- focus arborizing vessels can also be found in melanomas.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-16c
❑
❑
✔
❑
❑
❑
❑
❑
❑
DISPOSITION
ANSWERS
❑ No intervention
❑ Follow-up
❑
✔ Histopathologic diagnosis
Answers: 1,4,5
D E R M O S CO P I C C R I T E R I A
●
●
●
●
Arborizing vessels (black arrows)
Ulceration (yellow arrows)
Bluish-white color (stars)
Brown color (white arrows)
Discussion:
●
●
●
●
●
●
●
●
●
●
There are no criteria to diagnose a melanocytic lesion (ie pigment network,
globules)
● The foci of ovoid brown color are not a criterion that can be used to
diagnose a melanocytic lesion.
Arborizing vessels plus ulceration are the two major criteria to help make
the diagnosis.
Thick and thin bored arborizing vessels are classic.
Arborizing vessels can also be found in melanomas but much less frequently
than in basal cell carcinomas.
Out-of-focus vessels should raise a red flag for concern.
Out-of-focus arborizing vessels favor a diagnosis of melanoma.
It is not necessary to use a protractor to determine the angles of branching
vessels.
Angles are not of diagnostic significance.
The “classic” bluish-white veil is not present.
Blue and white colors are commonly found in basal cell carcinomas.
PEARLS
●
●
The stool quaic test can be used to differentiate an ulceration with blood
from an irregular melanocytic blotch, which would not contain heme.
At any location on the body, do not hesitate to cut off some hair to get a
better view.
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Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-17a1
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-17a2
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 17
H I S TO R Y
This 88-year-old woman has a biopsy proven basal cell carcinoma under a dark plaque. Clinically
both lesions seem to be connected.
QUESTIONS
1.
2.
3.
4.
Leaf-like structures fill the pigmented component of this basal cell carcinoma.
Asymmetrically pigmented follicular openings are plentiful.
A few rhomboid structures can be identified.
Irregular blotches with and without follicular openings indicate dermal invasion in this
melanoma.
5. Extensive regression characterizes this heavily pigmented basal cell carcinoma.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
Melanoma
Collision Zone
Basal Cell
Carcinoma
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-17b
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
2-17c
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
●
●
Follicular openings
(yellow arrows)
Asymmetrical follicular
pigmentation (black arrows)
Rhomboid structures (yellow
box)
Irregular blotch with follicular
openings (black box)
Irregular blotch without
follicular openings (stars)
Irregular dots and globules
(yellow circles)
Areas of regression (blue
arrows)
Polymorphous vessels
(red circles)
ANSWERS
Answers: 2,3,4
Discussion:
●
●
●
●
●
●
●
●
Clinically and dermoscopically, this is an obvious invasive melanoma.
The first step in the progression of melanoma on the face is represented by
asymmetrical follicular pigmentation.
● The follicular openings should not be confused with milia-like cysts seen
in seborrheic keratosis.
The next step in the progression of melanoma on the face is the formation
of rhomboid structures.
True “rhomboid” forms (parallelogram with unequal angles and sides) are
not necessary.
Any pigmented thickening that surrounds follicular openings should be
considered “rhomboid” structures.
Black irregular blotches surrounding follicular openings are the first sign of
dermal invasion.
Complete obliteration of follicular openings indicates further dermal invasion.
By definition, this is a collision tumor, representing a basal cell carcinoma
and melanoma.
PEARLS
●
●
●
One does not need dermoscopy to realize that this is high-risk pathology.
The diagnosis of melanoma on the face is not always this easy.
Dermoscopy is essential to help make the diagnosis in most cases of early
lentigo maligna, which offers the patients their best chance for survivial.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-18a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-18b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 18
H I S TO R Y
Over the past few months this asymptomatic pigmented skin lesion on a 74-year-old man has been
increasing in size and getting darker.
QUESTIONS
1. Milia-like cysts and pseudofollicular openings characterize this seborrheic keratosis.
2. The irregular blotch and areas of regression are important clues that this could be a
melanoma.
3. The multicomponent global pattern, asymmetry of color and structure, irregular dots and
globules, and an irregular blotch plus regression characterize this melanoma.
4. Multiple follicular openings are not identifiable.
5. Based on the history, clinical and dermoscopic appearance sequential digital dermoscopic
monitoring is indicated rather than a biopsy.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
1
❑ Low
❑ Intermediate
✔ High
❑
3
2
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-18c
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 2,3,4
Discussion:
●
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
●
Asymmetry of color and
structure
Multicomponent global
pattern (1,2,3)
Irregular dots and globules
(circles)
Irregular blotch (yellow arrows)
Regression (white arrows)
Peppering (box)
Follicular openings
(black arrows)
●
●
●
●
●
The history, clinical, and dermoscopic picture are worrisome.
There are no criteria to diagnosis a seborrheic keratosis.
The irregular black blotch could be seen in a heavily pigmented seborrheic
keratosis.
The typical site-specific and melanoma-specific criteria from the face are not
seen.
● Asymmetrical follicular pigmentation
● Annular-granular structures
● Rhomboid structures
● Circle within a circle
The regression area is not seen clinically.
The regression area consists of blue and white colors plus peppering.
One can expect to see multiple follicular openings on the face.
Follicular openings can be found outside of the lesion on normal skin.
PEARLS
●
●
●
●
A large dark pigmented lesion on the face should always raise a red flag for
concern.
A large facial lesion could be a congenital melanocytic nevus, solar lentigo,
or melanoma.
The absence of criteria that favor low-risk pathology (ie fingerprint pattern)
should raise a red flag for concern.
If the expected site-specific criteria are absent, use the pattern analysis
algorithm for the trunk and extremities or an algorithm of your choice to
evaluate the lesion.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
D I AG N O S I S
2-19a
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-19b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 19
H I S TO R Y
A total body skin examination was performed on this 70-year-old man at his first visit with a new
dermatologist. The patient was not aware of the lesion on his right ear lobe that the dermatologist found.
QUESTIONS
1. This is a classic pigmented seborrheic keratosis that does not need dermoscopic evaluation.
2. In order not to miss melanoma incognito, aka false negative melanomas, one should routinely
examine lesions that do not look atypical clinically.
3. Asymmetry of color and structure, irregular dots, globules and blotches, asymmetrical follicular pigmentation and regression characterize this melanoma.
4. Symmetry of color and structure, regular dots and globules, and blotches characterize this
small congenital melanocytic nevus.
5. The dramatic asymmetric follicular pigmentation should raise a red flag for concern.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-19c
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
ANSWERS
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
Answers: 2,3,5
Discussion:
●
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
●
Asymmetry of color and
structure
Follicular openings
(white arrows)
Asymmetrical follicular
pigmentation (black arrows)
Asymmetrical follicular
pigmentation units (white
boxes)
Irregular dots and globules
(circles)
Irregular blotches (black boxes)
Regression (stars)
●
●
●
●
●
●
The clinical differential diagnosis includes a seborrheic keratosis or
melanoma.
This would be an unusual location for both pathologies.
The fingerprint pattern, milia-like cysts, and pseudofollicular openings used
to diagnose a seborrheic keratosis are absent.
The asymmetrical follicular pigmentation units are dramatic.
One should not confuse the follicular openings with milia-like cysts of a
seborrheic keratosis.
One infers that there is regression based on the clinical appearance of the
lesion.
The regression areas are not well developed because the color is not whiter
than the surrounding skin.
Gray color and “peppering” are absent.
Criteria can be present yet do not always fit into the exact definitions given
to them.
PEARLS
●
●
●
●
In this location it is not always easy to identify the high-risk criteria.
It is essential to learn the definitions of the site-specific criteria.
It is essential to have a color atlas of dermoscopy images, in your mind, of
the important criteria.
Focus your attention and make a careful search for the melanoma-specific
criteria.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-20a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-20b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 20
H I S TO R Y
A 74-year-old man has this spot on his face, which has not changed for many years.
QUESTIONS
1. “Moth-eaten” convex borders and pseudopigment network, aka pseudonetwork, characterize
this solar lentigo.
2. “Moth-eaten” concave borders, pseudonetwork, remnants of a fingerprint pattern, and homogenous color characterize this solar lentigo.
3. The pigment network and pseudonetwork are both created by elongated hyperpigmented rete
ridges.
4. The pseudonetwork is found only on the face, nose, and ears, and diagnoses melanocytic
lesions.
5. The pseudonetwork can be seen in melanocytic and non-melanocytic lesions.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
✔ Low
❑
❑ Intermediate
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-20c
❑
❑
❑
❑
❑
❑
❑
✔
❑
DISPOSITION
✔ No intervention
❑
❑ Follow-up
❑ Histopathologic diagnosis
ANSWERS
Answers: 2,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
Sharp border demarcation
Concave “moth-eaten” borders
(black arrows)
Pseudonetwork (boxes)
Homogeneous color (stars)
Remnants of the fingerprint
pattern (white arrows)
●
●
●
●
●
●
The criteria to diagnose melanoma are not seen.
Typically, solar lentigines have sharp borders.
Typically, solar lentigines have concave borders, said to resemble a moth-eaten
garment, known as “moth-eaten borders.”
The pigment network found on the trunk and extremities is created by
elongated hyperpigmented rete ridges and is not usually seen on the face,
nose or ears.
Follicular and other appendageal openings that penetrate areas of pigmentation
create the pseudonetwork.
The terms pseudonetwork and pseudopigment network are used
interchangeably.
The fingerprint pattern made up of fine light brown parallel line segments
resembling finger prints differs from the honeycomb-like line segments of
the pigment network.
Well developed or fragments of the fingerprint pattern are commonly seen.
● In this case the fragments of the fingerprint pattern are very difficult to
see and could be easily overlooked.
PEARLS
●
●
●
Despite common teaching, there is no evidence to substantiate that the
pseudonetwork is a primary criterion to diagnose melanocytic lesions.
The pseudonetwork is site-specific and can be seen in melanocytic and
non-melanocytic lesions.
One has to identify other criteria to make a diagnosis once the pseudonetwork
is identified.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-21a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-21b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 21
H I S TO R Y
The pigmented skin lesion on the face of this 8-year-old boy was scheduled for excision by a plastic
surgeon, under general anesthesia, after the patient was referred by a pediatric dermatologist. The
dermatologist thought that it looked atypical clinically and there was a history of change. The
lesion was never examined with dermoscopy.
QUESTIONS
1. Asymmetry of color and structure, irregular dots, and globules characterizes this dysplastic
nevus.
2. Nodular melanoma is in the clinical and dermoscopic differential diagnosis.
3. Minimal asymmetry of color and structure, foci of pseudopigment network, and heavy
pigmentation characterize this small congenital melanocytic nevus.
4. Asymmetry of color and structure are commonly seen in congenital melanocytic nevi.
5. A history of change in a nevus is not always high risk, especially in a child.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
✔ Low
❑
❑ Intermediate
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-21c
✔
❑
❑
❑
❑
❑
❑
❑
❑
DISPOSITION
✔ No intervention
❑
❑ Follow-up
❑ Histopathologic diagnosis
ANSWERS
Answers: 3,4,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
Asymmetry of color and
structure
Appendageal openings
(arrows)
Pseudopigment network complex (homogeneous color and
follicular openings)
Regular dots and globules
(boxes)
●
●
●
Clinically and dermoscopically this is not high risk.
Asymmetry of color and structure are commonly found in congenital
melanocytic nevi of all sizes.
Other experienced dermoscopists might not agree that there is asymmetry
of color and structure.
The pseudopigment network is easy to identify and expected in this location.
At first blush this lesion is similar to Case 18; however, there are no welldeveloped melanoma-specific criteria.
PEARLS
●
●
●
The majority of pigmented skin lesions in children are not high risk.
Unnecessary surgery can be avoided in most children if dermoscopy is used.
No child should ever have a pigmented skin lesion biopsied or removed
before it is examined with dermoscopy.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-22a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-22b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 22
H I S TO R Y
A 65-year-old man was referred by another dermatologist to evaluate this lesion with dermoscopy
to determine if it should be biopsied. This history of the lesion is not known by the patient.
QUESTIONS
1. Clinically and dermoscopically a solar lentigo and in situ melanoma are in the differential
diagnosis.
2. There are no high-risk dermoscopic features in this solar lentigo.
3. The linear tracks and globules diagnose a melanoma.
4. Linear tracks and linear globules can be seen in benign and malignant pathology.
5. The “peppering” seen in this lesion indicates that there is a component of trauma.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
✔ Intermediate
❑
❑ High
1
D I AG N O S I S
2
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
3
2-22c
❑
❑
❑
❑
❑
❑
❑
✔
❑
4
ANSWERS
Answers: 1,4,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Asymmetry of color and
structure
Multicomponent global pattern
(1,2,3,4)
Irregular linear globules
(yellow box)
Irregular linear lines aka train
tracks (arrows)
Irregular thick network
(black box)
Peppering (white box)
●
●
●
●
●
Most solar lentigines on the lips have a banal dermoscopic appearance
(ie homogeneous brown color, fine parallel lines).
It is not always possible to differentiate a solar lentigo from in situ
melanoma clinically and with dermoscopy.
In such situations a biopsy is indicated.
Several distinct patterns of criteria can be seen on the lips and in genital
mucosa (non-glabrous skin):
● Regular or irregular linear globules
● Parallel lines of globules sometimes creating a “fingerprint” pattern
● Single thin or thick lines
● Two parallel lines the “train track” pattern
● Multiple parallel line segments another “fingerprint” pattern
● Thin or thick network-like structures
“Peppering” indicates trauma unless other high-risk criteria are seen.
Asymmetry of color and structure, a multicomponent global pattern, and
irregular criteria should raise a red flag for concern.
Blue-white color, dark irregular blotches, and polymorphous vessels not
identified here are seen in invasive melanoma.
PEARLS
●
●
●
Surgery can be avoided in most cases after a banal picture is seen with
dermoscopy.
In gray-zone lesions sequential digital dermoscopic monitoring can be used.
The most atypical dermoscopic area should be used for an incisional biopsy.
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Page 73
Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-23a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-23b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 23
H I S TO R Y
This 57-year-old man’s main complaint was a slowly enlarging spot on his nose.
QUESTIONS
1. Arborizing telangiectases must always be present to diagnose a basal cell carcinoma on the
nose.
2. The vessels in this lesion fall within the range of vessels that can be seen in basal cell carcinomas.
3. Blue, black, gray, brown, red, and white colors can be seen in basal cell carcinomas.
4. Asymmetry of color and structure, multiple colors, dots and globules, plus telangiectatic vessels
characterize this pigmented basal cell carcinoma.
5. Pigment network, ovoid nets of blue pigment, ulceration, spoke-wheel structures, plus arborizing
vessels are the criteria used to diagnose basal cell carcinomas.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
❑
❑
✔
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-23c
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 2,3,4
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Asymmetry of color and
structure
Non-arborizing telangiectatic
“basal cell–like” vessels (black
arrows)
Blue globules (yellow arrows)
Brown dots and globules (circle)
Multiple colors—brown, blue,
white
Appendageal openings
(red arrows)
Discussion:
●
●
●
●
●
●
●
Classic thick and thin arborizing vessels are not always found.
On occasion, pinpoint, hairpin, linear, kinked, and other shaped telangiectatic vessels can be seen with or without arborizing vessels.
The classic description of pigmentation that can be found in basal cell
carcinomas includes: large gray-blue ovoid nests, gray-blue dots and globules,
and leaf-like structures.
Be aware that there are innumerable variations of size and shape of the
pigmentation found in basal cell carcinomas.
The absence of a pigment network helps to differentiate this from a
melanoma.
Pigment network is not seen in basal cell carcinomas.
In order to diagnose a basal cell carcinoma there must not be a pigment
network.
PEARLS
●
●
●
●
It is important to learn the definitions of the types of pigment that can be
found in basal cell carcinomas.
It is not essential to perfectly fit pigmentation into the specifically defined
shapes and colors.
If one follows the definition of how leaf-like structures should look, one will
realize that they never look like any type of leaf!
The concept of leaf-like structures is a misnomer that should be abandoned.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-24a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-24b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 24
H I S TO R Y
A 71-year-old man’s barber found this asymptomatic lesion on his scalp.
QUESTIONS
1. Multiple brown globules categorize this as a melanocytic lesion.
2. The multicomponent global pattern and asymmetry of color and structure are significant red
flags for concern.
3. Irregular dots and globules and a large irregular black blotch are more reason for concern.
4. The blue-white and gray colors of regression points in the direction of a melanoma.
5. Even though streaks and polymorphous vessels are absent, this still could be a melanoma.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
1
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
❑ No intervention
❑ Follow-up
❑
✔ Histopathologic diagnosis
2
3
4
2-24c
❑
❑
❑
❑
❑
❑
✔
❑
❑
ANSWERS
Answers: 1,2,3,4,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
Asymmetry of color and
structure (+)
Multicomponent global pattern
(1,2,3,4)
Irregular globules (circles)
Irregular blotch (stars)
Regression (arrows)
●
●
●
●
It is essential to include the scalp in a total body skin examination.
Criteria used to diagnose benign pathology are not seen (ie cobblestone
pattern, milia-like cysts, brain-like pattern).
Superficial spreading and nodular melanoma are typically found on the scalp.
One should have a systematic check list of criteria that need to be identified.
Go over the checklist with each lesion:
● Step 1: Is the lesion melanocytic or non-melanocytic?
If the lesion is melanocytic:
● Step 2: To determine if it is low, intermediate, or high risk using the
algorithm of your choice.
If using pattern analysis:
● Step 3: What is the global pattern?
● Step 4: Is there symmetry or asymmetry of color and structure?
● Step 5: Identify the local criteria and determine if they are regular or
irregular, good or bad, low or high risk.
● Step 6: Put everything together and make a dermoscopic diagnosis
Do not make a dermoscopic diagnosis before identifying all of the criteria in
a lesion
PEARLS
●
●
●
Bright light is essential for a good scalp examination.
The entire scalp should be carefully checked when doing a complete skin
examination.
The sooner the checklists are memorized, the sooner one is on their way to
becoming a well-organized dermoscopist.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
D I AG N O S I S
2-25a
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-25b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 25
H I S TO R Y
A 77-year-old man was not aware of the pigmented lesion on his ear.
QUESTIONS
1. There are multiple asymmetrically pigmented follicular openings.
2. There are foci of rhomboid structures.
3. The irregular blotch with follicular openings indicates dermal invasion of this lentigo maligna
melanoma.
4. The irregular blotch without follicular openings represents the “black lamella” indicating this
pigmented lesion is benign.
5. If one has good eyesight and can perform a biopsy, dermoscopy is not helpful to diagnose
lentigo maligna and its variants.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
2-25c
❑
❑
❑
❑
❑
❑
✔
❑
❑
ANSWERS
Answers: 1,2,3
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Asymmetry of color and
structure
Follicular openings (red
arrows)
Asymmetrical follicular pigmentation (black arrows)
Irregular black blotch with
follicular openings (white
arrows)
Irregular black blotch without
follicular openings (yellow
arrows)
Rhomboid structures (white
boxes)
●
●
●
●
●
●
Clinically, but not dermoscopically, this could be a seborrheic keratosis or
melanoma.
There are no dermoscopic criteria to diagnose a seborrheic keratosis (ie
milia-like cysts, pseudofollicular openings, fingerprint pattern).
The “black lamella” could look like this—a black homogenous blotch with a
glazed look.
The “black lamella” created by pigmented parakeratosis is not seen in
melanoma.
Tape stripping often removes the “black lamella.”
Tape stripping will not remove the irregular black blotch in this melanoma.
By now the diagnosis should be relatively easy.
There are many faces of melanoma and the diagnosis will not always be so
easy.
PEARLS
●
●
●
One should memorize the criteria that are needed to diagnose lentigo
maligna and lentigo maligna melanoma.
One should have images of the classic examples of the high-risk criteria
cemented in their minds.
Focus ones attention to make the diagnosis.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-26a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-26b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 26
H I S TO R Y
A 76-year-old man has several gray scaly spots on his face that are sensitive to touch.
QUESTIONS
1. The clinical impression of a melanoma with regression is supported by the dermoscopic
picture.
2. The gray pseudonetwork seen here is created by confluent annular-granular structures.
3. Annular-granular structures can be seen in pigmented actinic keratosis, lichen-planus keratosis,
and lentigo maligna.
4. Annular-granular structures are the only criterion that is 100% diagnostic of lentigo maligna.
5. Multiple scaly lesions favor a diagnosis of pigmented actinic keratosis.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
✔ Intermediate
❑
❑ High
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-26c
❑
❑
❑
❑
❑
❑
❑
✔
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 2,3,5
Discussion:
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
Follicular openings (arrows)
Annular-granular structures
(circles)
Gray pseudonetwork (box)
Brown color (star)
●
●
●
●
●
●
Annular-granular structures are created by fine gray or brown dots that
surround follicular openings.
When gray they can represent melanophages and/or free melanin or atypical
melanocytes.
Annular-granular structures can be localized or diffuse.
Confluent annular-granular structure creates the gray pseudonetwork.
The differential diagnosis in this case includes: pigmented actinic keratosis,
lichen planus keratosis, and lentigo maligna.
Clinical sensitivity often expressed by patients favors the diagnosis of
pigmented actinic keratosis.
Diffuse “peppering” and remnants of an actinic lentigo or flat seborrheic
keratosis (fingerprint pattern) are characteristic of lichen planus keratosis.
PEARLS
●
●
●
●
Pigmented actinic keratosis and solar lentigines can be associated with lentigo
maligna.
Look for other criteria associated with lentigo maligna before making a final
diagnosis of a pigmented actinic keratosis.
Use the most atypical area for an incisional biopsy
A rough scaly pigmented area is a clue that a lesion with this dermoscopic
picture is a pigmented actinic keratosis.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-27a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-27b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 27
H I S TO R Y
A 68-year-old man has an asymptomatic spot on his nose that was discovered by his wife.
QUESTIONS
1.
2.
3.
4.
5.
This barely visible tan macule does not warrant dermoscopic examination.
Multiple milia-like cysts and pseudofollicular openings diagnose a seborrheic keratosis.
Asymmetry of color and structure are a red flag for concern.
Asymmetrical follicular pigmentation is another red flag for concern.
For cosmetic reasons this lesion could be treated with liquid nitrogen without a biopsy.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-27c
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 3,4
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Asymmetry of color and
structure
Different shades of brown and
gray color
Follicular openings (black
circles)
Asymmetrical follicular
pigmentation (boxes)
Irregular globules (yellow circle)
Poorly defined border (black
arrows)
●
●
●
●
●
●
●
Compared with all of the cases with the same diagnosis, the dermoscopic
picture is not dramatic.
One should not confuse the follicular openings with milia-like cysts of a
seborrheic keratosis.
The overall picture is that of an irregular pseudonetwork.
A uniform pseudonetwork would be made up of light brown homogeneous
color studded with monomorphous round follicular openings. There would
not be asymmetrical follicular pigmentation.
One must focus attention to find the asymmetrically pigmented follicular
openings.
Use the area with asymmetrically pigmented follicular openings if an incisional
biopsy is performed.
The criteria for a solar lentigo (fingerprint pattern) are absent.
Poorly defined borders seen here do not favor a solar lentigo.
Sharp concave “moth-eaten” border favors a solar lentigo.
PEARLS
●
●
●
●
●
Banal appearing pigmentation can represent lentigo maligna.
Dermoscopy should not only be used to examine atypically pigmented skin
lesions in order not to miss melanoma incognito.
In this clinical scenario, an important clue is the absence of the fingerprint
pattern. Immediately one should think this could be lentigo maligna and
carefully search for the diagnostic criteria.
This case points out the benefits of dermoscopy to diagnose early lentigo
maligna.
Use a Woods light to determine the extent of the pigmentation.
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-28a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-28b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 28
H I S TO R Y
A 36-year-old woman has this brown spot on her face for a few years. It is asymptomatic and there
is no history of change.
QUESTIONS
1. Different shades of brown and gray colors plus asymmetry of color and structure are a red flag
for concern.
2. The uniform pseudonetwork rules out lentigo maligna.
3. There are only two asymmetrically pigmented follicular openings.
4. The light areas have a differential diagnosis that includes hypopigmentation, areas of
inflammation, or regression.
5. Well developed “moth-eaten” borders and fingerprint structures diagnose a solar lentigo.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-28c
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 1,3,4
Discussion:
●
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Asymmetry of color and
structure
Different shades of brown and
gray color
Follicular openings (yellow
boxes)
Asymmetrical follicular
pigmentation (black boxes)
Irregular dots and globules
(circles)
Multifocal hypopigmentation
(stars)
●
●
●
●
●
The dermoscopic picture is not perfectly banal appearing.
A uniform pseudonetwork is not seen.
One cannot determine if there are classic “moth-eaten” borders and sharp
demarcation.
There are only two asymmetrically pigmented follicular openings that even
experienced dermoscopist might not see.
The hypopigmented areas have a grayish tinge, which suggests that there is
inflammation.
True regression is not seen.
Well-formed melanoma- specific criteria are absent.
The irregular dots and globules are a minor criterion that has no diagnostic
significance.
PEARLS
●
●
●
Sequential digital dermoscopic monitoring would be one alternative to a
biopsy in this cosmetically important area.
One must be as knowledgeable as possible with difficult cases like this, in
order to form a meaningful differential diagnosis.
Look carefully for high-risk criteria before making a benign dermoscopic
diagnosis.
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Page 85
Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-29a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 29
H I S TO R Y
A less-experienced colleague e-mails you this image and wants to know if you think a biopsy is
indicated. A history and clinical image were not supplied.
QUESTIONS
1.
2.
3.
4.
5.
There are annular-granular structures.
There is asymmetry of color and structure.
There is asymmetrical follicular pigmentation.
The borders are poorly defined.
The differential diagnosis includes a pigmented actinic keratosis vs lentigo maligna.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
2-29b
❑
❑
❑
❑
❑
❑
✔
❑
❑
ANSWERS
Answers: 1,2,3,4,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Asymmetry of color and
structure
Different shades of tan and
gray colors
Follicular openings (black
arrows)
Asymmetrical follicular
pigmentation (boxes)
Annular-granular structures
(circles)
“Moth-eaten” borders
(red arrows)
●
●
●
●
The striking dermoscopic findings are the annular-granular structures and
asymmetrical follicular pigmentation.
Once again there is an irregular pseudonetwork indicating the lesion is on
the face.
The annular-granular structures and follicular pigmentation are side by side
in this lesion.
Interobserver agreement might be in conflict regarding the presence or
absence of “moth-eaten” borders.
Your advice to your colleague would include the differential diagnosis:
pigmented actinic keratosis vs lentigo maligna.
Your colleague should biopsy the area with annular-granular structures and
asymmetrical follicular pigmentation.
PEARL
●
●
●
●
With knowledge and experience one can come up with a diagnosis, differential diagnosis, and plan without a history or clinical image just based on the
dermoscopic picture.
Make sure that your pathologist is a pigmented lesion expert.
The histopathology of an actinic keratosis could be confused with lentigo
maligna.
If one thinks the lesion is a lentigo maligna but the biopsy reports an actinic
keratosis biopsy in another area.
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Page 87
Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-30a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-30b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 30
H I S TO R Y
Two dermatologists saw this lesion and said it was benign. They did not examine it with dermoscopy.
QUESTIONS
1.
2.
3.
4.
5.
The roundish white structures could be milia-like cysts.
The roundish white structures could be follicular openings.
“Moth-eaten” borders diagnose a solar lentigo.
Irregular dots and globules are a red flag for concern.
Foci of asymmetrical follicular pigmentation are present.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
❑
❑
❑
❑
❑
❑
✔
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
Lentigo maligna
Solar lentigo
ANSWERS
Answers: 1,2,4,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Asymmetry of color and
structure
Different shades of brown
color
Follicular openings
(black arrows)
Annular-granular structures
(circle)
Asymmetrical follicular
pigmentation (boxes)
“Moth-eaten” borders
(red arrows)
2-30c
D I AG N O S I S
●
●
●
●
●
●
●
A large solitary lesion on the face is the first red flag for concern.
The differential diagnosis of the round structures includes follicular openings versus milia-like cysts.
There are no other criteria seen in seborrheic keratosis.
The entire picture is that of an irregular pseudonetwork.
The “moth-eaten” borders are not enough to diagnose a solar lentigo.
Knowing that there is an association between solar lentigo and lentigo
maligna was important in this case.
Two biopsies were performed for academic reasons.
The right side diagnosed a solar lentigo.
The left side diagnosed lentigo maligna.
PEARLS
●
●
If one cannot differentiate a seborrheic keratosis from a melanocytic lesion
based on the dermoscopy, look and palpate the lesion to help make the differentiation.
Putting as much of the clinical picture together as possible is the best way to
make the correct diagnosis.
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Page 89
Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
D I AG N O S I S
2-31a
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-31b
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 31
H I S TO R Y
A 55-year-old man thought that a lesion on his forehead was getting darker.
QUESTIONS
1. Pseudofollicular openings, peppering, and remnants of the fingerprint pattern characterize this
irritated seborrheic keratosis.
2. The gray pseudonetwork diagnoses a pigmented actinic keratosis.
3. Multiple circles within a circle are a red flag for concern and diagnose lentigo maligna.
4. Asymmetrical follicular pigmentation could be confused with circles within a circle structures.
5. Multiple milia-like cysts are enough to diagnose a seborrheic keratosis.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-31c
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 3,4
Discussion:
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
●
●
Asymmetry of color and
structure
Hair shafts (black arrows)
Follicular pigmentation (yellow
arrows)
Circle within a circle units
(black boxes)
Asymmetrical follicular
pigmentation (white box)
Fingerprint pattern (red box)
Gray dots and globules
(yellow box)
Gray color (stars)
●
●
●
●
●
At first blush, the striking asymmetry of color and structure should be a red
flag for concern.
Annular-granular structures vs peppering seen throught the lesion is the
differential diagnosis for the gray color—another red flag for concern
Circle within a circle is a unique structure composed of a central hair shaft
and gray pigmentation (atypical melanocytes) that surround the follicle.
The differential diagnosis for the circle within a circle would be asymmetrical follicular pigmentation, pseudofollicular openings, and milia-like cysts.
The central hair shaft differentiates the circle within a circle from follicular
openings with pigmentation.
A focus of well-developed fingerprint pattern (parallel line segments) makes
the dermoscopic association of lentigo maligna and solar lentigo.
PEARLS
●
●
●
●
●
●
The German philosopher Johann Wolfgang Goethe once wrote “One cannot
see what one does not know.”
The concept of circle within a circle is not well known.
Circle within a circle might be the only criterion to diagnose lentigo
maligna.
Mastering dermoscopy by “osmosis” cannot be done.
Put in the time to learn as much dermoscopy as possible.
The learning curve is steep!
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-32a
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
2-32b1
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
CASE 32
H I S TO R Y
These two asymmetric lesions were found on the forehead of a 70-year-old man with a history of
actinic keratosis, basal, and squamous cell carcinoma.
LESION 1
QUESTIONS
1. Globules diagnose a melanocytic lesion.
2. Irregular pigmented pseudofollicular openings and milia-like cysts diagnose a seborrheic
keratosis.
3. On close inspection there is significant asymmetry of color and structure.
4. The blue-white color and irregular dark blotches are a red flag for concern.
5. This could not be a melanoma because the typical site-specific and melanoma-specific criteria
are not seen.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
1
2
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
3
2-32b2
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 1,3,4
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
●
Asymmetry of color and
structure
Multicomponent global pattern
(1,2,3) vs
Irregular cobblestone global
pattern (irregular large
angulated globules)
Irregular dots and globules
(circles)
Irregular blotches (star and
yellow arrows)
Blue-white color (white arrows)
Asymmetrical follicular
pigmentation (red arrows)
●
●
●
●
At first blush this looks more like a seborrheic keratosis than melanoma.
The irregular dots and globules could be confused with pigmented
pseudofollicular openings characteristic of a seborrheic keratosis.
A melanoma on the face with a cobblestone-like pattern is very unusual.
The bizarre-shaped blotches (yellow arrows) favor the diagnosis of irregular
pseudofollicular openings.
The bluish-white color and large dark blotch could be found in a seborrheic
keratosis.
This difficult case could lead to a misdiagnosis with the initiation of
inappropriate destructive therapy before making a histopathologic diagnosis.
PEARLS
●
●
●
This lesion points out the need for a differential diagnosis for global patterns,
local criteria, and the potential diagnosis.
If destructive therapy in a lesion like this is not successful, it is better to
make a histopathologic diagnosis as soon as possible rather than carrying
out additional blind destructive therapies.
Dermoscopy is not a perfect technique. Don’t expect it to be!
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Chapter 2
Sc a l p, Face, N ose and Ea r s
RISK
❑ Low
❑ Intermediate
❑ High
2-32c1
D I AG N O S I S
❑
❑
❑
❑
❑
❑
❑
❑
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
DISPOSITION
❑ No intervention
❑ Follow-up
❑ Histopathologic diagnosis
LESION 2
QUESTIONS
1.
2.
3.
4.
5.
The classic pseudonetwork diagnoses a solar lentigo.
Ulceration and pigmentation characterize this basal cell carcinoma.
Different shades of pink and brown are a red flag for concern.
Several asymmetrically pigmented follicular openings are an important high-risk clue.
This could be a feature-poor melanoma.
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D E R M O S CO P Y: A N I L LU S T R AT E D G U I D E
RISK
❑ Low
❑ Intermediate
✔ High
❑
D I AG N O S I S
Benign Nevus
Seborrheic keratosis
Basal cell carcinoma
Vascular
Dermatofibroma
Squamous cell carcinoma
Melanoma
Other
2-32c2
❑
❑
❑
❑
❑
❑
✔
❑
❑
DISPOSITION
❑ No intervention
❑ Follow-up
✔ Histopathologic diagnosis
❑
ANSWERS
Answers: 3,4,5
Discussion:
●
●
D E R M O S CO P I C C R I T E R I A
●
●
●
●
●
●
Different shades of pink and
brown color
Regression (stars)
Asymmetrical follicular pigmentation (yellow boxes)
Irregular dots and globules
(black box)
Scale (red arrows)
Ulceration (black arrows)
●
●
●
●
●
●
The pink color is the first clue of potentially high-risk pathology
Two completely different, appearing side by side, melanomas in the same
patient is extremely unusual.
Complete clinical and histopathologic separation rules out a single
melanoma.
The lesion is feature-poor because there are not well-defined high-risk criteria.
The pigmented follicular openings could be missed even by the most
experienced dermoscopist.
Different shades of brown and especially pink color are clues to the seriousness
of this lesion.
The irregular dots and globules are a clue that the lesion is melanocytic.
The ulceration was created by trauma.
PEARLS
●
●
●
Even the most experienced dermoscopist routinely has difficult cases in
which dermoscopy is inconclusive.
It is a fact of life that everyone misses or misdiagnoses melanoma.
Demoscopists have a much better chance to avoid this unpleasant situation.